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Fatal Combination of Ecstasy and Heroin

TO THE EDITOR: In their article, Jessica R. Oesterheld, M.D., et al.¹ stated that the proserotonergic effects of 3,4-methylenedioxymethamphetamine (MDMA or Ecstasy) can be augmented by ingestion of other proserotonergic drugs (e.g., fluoxetine, amphetamine, tramadol, or lithium). According to them, the most serious cases of central serotonin syndrome can develop with drugs that block both serotonin "exits": reuptake and monoamine oxidase. MDMA-related deaths have been reported from interactions with monoamine oxidase inhibitors.¹

The authors did not mention an interesting combination of MDMA/amphetamines and heroin. In one case, the combined action of heroin and amphetamines prevented death.² In another case, the combination of MDMA and heroin had a lethal outcome. The circumstances of the death (prelethal symptoms of central serotonin syndrome) suggested that MDMA’s proserotonergic effects were augmented by heroin.³ The mechanism of such an action is not clear. Further research is needed to understand how heroin heightens the effect of Ecstasy.

REFERENCES

1. Oesterheld JR, Armstrong SC, Cozza KL: Ecstasy: pharmacodynamic and pharmacokinetic interactions. Psychosomatics 2004; 45:84–87[Abstract/Free Full Text]
2. Jorens PG, Heytens L, Demey HE, Andries S, Ricaurte GA, Bossaert L, Schepens PJ: Acute poisoning with amphetamines (MDEA) and heroin: antagonistic effects between the two drugs. Intensive Care Med 1996; 22:456–459[Medline]
3. Gerevich J, Bácskai E, Kerekes MF, Kiss N, Csorba J: Halálos kimenetel heroin és Ecstasy együtthatás. Adalék a drogok kombinációjából ered ártalmak kérdéséhez (Combination of heroin and Ecstasy with fatal outcome: contribution on the question of harms arising from the combination of drugs). Psychiatria Hungarica 2000; 15:583–586

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